Provider Demographics
NPI:1710970520
Name:MCCORMACK, CARTER JAMESON (MD)
Entity Type:Individual
Prefix:
First Name:CARTER
Middle Name:JAMESON
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6303
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:1012 MEDICAL RIDGE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-4542
Practice Address - Country:US
Practice Address - Phone:864-833-3852
Practice Address - Fax:864-938-0501
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33343208600000X
NJMA71345208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3271200Medicaid
SC333437Medicaid
SC333437Medicaid
SCAA66347951Medicare PIN
NJE15617Medicare UPIN